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Rapid Responses: Rapid Responses published:
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History Irrelevant?
- Dr.Pankaj Arora (15 November 2003)
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Verbal and non-verbal communication
- Lewis Walker (17 November 2003)
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Re: Verbal and non-verbal communication
- Dominic J Stevens (20 November 2003)
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The value of history taking
- raymond hoffenberg, Malcolm Gough, John Ledingham (29 November 2003)
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Dr.Pankaj Arora, Dy.Chief Medical Officer ITI Hospital Mankapur,U.P. India 271308
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Sir, With due respect I would beg to differ with you on your statement “ “First take a thorough history" is the UNHELPFUL advice from textbooks.” And “How effective any of this is remains LARGELY UNKNOWN.” (Emphasis mine). I am a functional GP with a specialization in Medico-legal medicine and have found NO RESOURCE AS HELPFUL as the medical history in arriving at a provisional/differential diagnosis. The initial 1 minute or so of consultation, when the patient walks into the clinic and elucidates his/her complaints results in a provisional diagnosis in a majority of the cases and future questions directed at confirming or excluding other related conditions usually result in a relatively sure diagnosis, to be CONFIRMED by future investigations if need be. I am grateful to my seniors and the textbooks for having emphasized this aspect of the clinical consultation and my patients and I have benefited immensely from this “Mantra”. Competing interests: GP |
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Lewis Walker, GP Ardach Health Centre, Highfield Road, Buckie, AB56 1JE
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Dear Editor, The author of this article wrote :"Answers people give verbally may differ from those given on paper." However verbal and written answers are not the only form of communication. More than 50% of communication is transmitted non-verbally. It is not merely what you say but HOW you say it that counts (voice tone, tempo, postures, gestures etc). The non-verbal messages may or may not be congruent with the spoken word. Conditions such as depression may present with such incongruencies, so to rely merely on the words may miss important elements of affect displayed non-verbally. Effective GP's develop good rapport with their patients. This sensitises them to ALL aspects of communication. In fact my rule is that "any patient who depresses me has depression, until proved otherwise." I have found that this has helped me to pick up cases that may have gone unnoticed by words alone. Sincerely, Lewis Walker. Ref Walker, L. Consulting with NLP :neurolinguistic programming in the medical consultation. Radcliffe Medical Press 2002. Competing interests: I am the author of the quoted reference |
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Dominic J Stevens, Salried GP South Lambeth Rd Practice. SW8 1UL
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If a patient is angry I assume depression. If no eye contact on first greeting - the same. And if there is no smile until accepting the prescription for SSRI - confirmation.
Competing interests: None declared |
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raymond hoffenberg, retired n/a, Malcolm Gough, John Ledingham
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As three retired consultants, two physicians and a surgeon, we are prepared to take the risk that our views concerning the editorial by del Mar and Glasziou of 15 November may be considered to be outdated. We wish to express our dismay at their denigration of the importance of proper history taking in clinical practice. As proponents of evidence based medicine can they produce evidence that taking a proper history is "unhelpful"? There is evidence to the contrary in the paper by Hampton et al (1)who showed that after reading the referral letter and taking a history the definitive diagnosis was reached in 66 of 80 new outpatients, the physical examination being useful in only 7 patients and laboratory investigations in a further seven. If in del Mar and Glasziou's experience history taking really is a "muddle of questions", it reflects poor teaching in clinical method which both authors - as teachers in the Medical School in Brisbane - could have tried to improve instead of dismissing. Taking a proper history means listening carefully to what the patient has to say, followed by relevant systematic and constructive questions. As examples of clinical situations in which this discipline yields rich rewards we would cite the elucidation of chest pain or the recognition of da Costa's syndrome (2), where a proper history could save expensive and anxiety-producing investigations. The other extraordinary distortion of clinical practice is their statement that "currently deciding on what diagnostic manoeuvre to undertake is largely based on habit and ritual rather than anything rational". Again, what is the evidence for this disparaging statement, which also reflects bad teaching and is foreign to our experience of clinical practice among most doctors we have worked with? As justificatrion for their curious views concerning "the dawn of a new phase of evidence based medicine" they state that "deciding the diagnosis and prognosis takes up more time the actually intitiating treatment". Do they seriously wish to imply that one should cut corners in making a diagnosis and undertake treatment on the basis of one or two questions, however evaluated? To support their claim of the usefulness of abbreviated history taking they quote the Mini-Cog test for dementia that takes ony two minutes. The paper they quote (3) to endorse this view was followed by another from the same authors (4) reporting 76% sensitivity and 89% specificity for the test. Would del Mar and Glasziou be prepared to act - treat? - on such imprecise correlations without further verification? Would this really save precious time? The traditional method of thorough history taking and physical examination and thinking about what tests, if any, are needed may take somewhat longer, but must remain the cornerstone of clinical practice. We sympathise with the interest the authors show in the use of simple and accurate tests to assist diagnosis, but not with many of the views they express. If pursued,they could lead to the demise of clinical practice and the initiation of treatment after a simple interaction between the patient and a computer screen. What are really needed are measures that will give all doctors more time with their patients than the current deplorable situation allows. M Gough, Honorary Consultant in General Surgery, Oxford Radcliffe NHS Trust R Hoffenberg, Emeritus Professor of Medicine, University of Birmingham and late Visiting Professor University of Queensland J Ledingham, Emeritus Professor of Clinical Medicine, University of Oxford References I. Hampton JR, Harrison, MJG, Mitchell, JRA, Prichard JS, Seymour, C. Relative contributions of history taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients BMJ 1975 2 486-489 2. Wood P. Da Costa's Syndrome (or Effort Syndrome) BMJ 1941 1 767,805,845 3. Scanlan J and Borson S The Mini-Cog: receiver operating characterisitics with expert and naive raters. Int J Geriatr. Psychiatry 2001, 16, 316-322 4. Borson,S, Scanlan JM, Chen P, Ganguli M. The min-cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 3002 Oct,51910):1451-4 Competing interests: None declared |
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